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Anticoagulation practices and the prevalence of major bleeding, thromboembolic events, and mortality in venoarterial extracorporeal membrane oxygenation (VA-ECMO): A systematic review and meta-analysis

Abstract Purpose To evaluate the safety of anticoagulation in venoarterial extracorporeal membrane oxygenation (VA-ECMO). Design We performed a systematic review and meta-analysis using multiple electronic databases. Studies were from 1977 to September 27, 2016. We evaluated the effect of anticoagul...

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Published in:Journal of critical care 2017-06, Vol.39, p.87-96
Main Authors: Sy, Eric, MD, Sklar, Michael C., MD, Lequier, Laurence, MD, Fan, Eddy, MD, PhD, Kanji, Hussein D., MD, MSc, MPH
Format: Article
Language:English
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Summary:Abstract Purpose To evaluate the safety of anticoagulation in venoarterial extracorporeal membrane oxygenation (VA-ECMO). Design We performed a systematic review and meta-analysis using multiple electronic databases. Studies were from 1977 to September 27, 2016. We evaluated the effect of anticoagulation in VA-ECMO on outcomes including major bleeding, thromboembolic events, and in-hospital mortality, using a random effects model meta-analysis. Results 26 studies (1496 patients) were included. Ten studies only had patients with post-cardiotomy shock, four studies only included extracorporeal cardiopulmonary resuscitation patients, and ten studies had a mixture of patients. Most studies (n = 17) were low quality with a Newcastle-Ottawa Scale score ≤ 5. The summary prevalence of major bleeding was 27% (95% CI, 18–35%), with considerable between-study heterogeneity ( I2 = 91%). Major bleeding requiring re-operation was the most common bleeding event. The summary prevalence of thromboembolic events was 8% (95% CI, 4–13%, I 2 = 83%). Limb ischemia, circuit-related clotting, and stroke were the most commonly reported events. The summary prevalence for in-hospital mortality was 59% (95% CI, 52–67%, I 2 = 78%). Conclusions The optimal targets and strategies for anticoagulation in VA-ECMO are unclear. Evaluation of major bleeding and thromboembolic events is limited by study quality and between-study heterogeneity. Clinical trials are needed to investigate the optimal anticoagulation strategy.
ISSN:0883-9441
1557-8615
DOI:10.1016/j.jcrc.2017.02.014